Telehealth in patient care: The bell can’t be unrung

Dr. Dorian Traube, Ph.D., LCSW, an associate professor in the Suzanne Dworak Peck School of Social Work at the University of Southern California (USC), believes telehealth is here to stay. “I think it’s hard to unring a bell. I expect that we will continue to have telehealth access. There’s certainly a lot of work to be done on the provider and consumer side regarding which services are best provided by telehealth, or adequately provided by telehealth. I don’t expect that we will keep seeing patients at the same rate that we have been, because we will have more options for on-the-ground and online service utilization. But I don’t expect us to go back to pre-pandemic telehealth service utilization rates, just because people have seen the convenience on both ends, for both the patient and the provider.”

In fact, Dr. Traube’s own career illustrates the massive increase in telehealth quality and accessibility over the 21st century. When she began her telehealth practice in New York in 2002 to support people who were homebound due to multiple sclerosis, appointments were conducted through conference calls. In those pre-videoconferencing technology days, it was “wonderful to connect with people, but challenging not to see people and to make connections with clients,” she recalls. Dr. Traube moved to California and became interested in training child development professionals to deliver telehealth, establishing a program that provided 2,000 telehealth home visits and trained 25 students in the four years prior to the COVID-19 pandemic. The lack of reimbursement for telehealth services made the program “unsustainable,” as many patients weren’t able to afford out-of-pocket services.

Throughout 2020, the lifting of telehealth reimbursement limitations and licensing restrictions fueled fast-paced growth. During the pandemic, the organizations that Dr. Traube works with have delivered over 600,000 telehealth appointments and trained over 12,000 providers. These include early childhood educators, social workers, and people trained in behavioral health.

Before beginning to talk about telehealth laws, it’s helpful to define “telehealth” itself. Telehealth is broadly defined as the use of electronic and telecommunications technologies to deliver clinical healthcare services, patient education, public health, and health administration. Therefore, telehealth covers services delivered by videoconference, remote patient monitoring, and store-and-forward (also known as “asynchronous telemedicine”).

Telehealth can overlap with mobile health but is not interchangeable with mobile health, as mobile health is delivered exclusively via mobile devices (smartphones and tablets), whereas telehealth may use other devices (such as laptops) for delivery.

In general use, the term “telehealth” is often used interchangeably with “telemedicine,” although telemedicine usually focuses on medical practice via remote means.

According to the Centers for Medicare and Medicaid Services (CMS), use of virtual visits (video- or phone-based visits) among Medicare patients during the pandemic’s early weeks increased by over 11,000% as compared to pre-pandemic. In the week ending April 18, 2020, almost 1.3 million Medicaid beneficiaries received telehealth services. Compared to a mere 11,000 in the week ending March 7, 2020, this represented an 11,718% jump in only 1.5 months.

Before the pandemic, Dr. Carrie Singer, a clinical psychologist and Executive Director of Quince Orchard Psychotherapy saw patients almost exclusively in person. “Patients were resistant to telehealth before COVID-19. They thought it wouldn’t feel as personal or connected.” But in the last year and a half the practice has moved primarily to video visits, which has worked well and increased access to many new patients—some of whom actually prefer the convenience and flexibility. “We’ve seen so much interest from new patients, it can actually be kind of discouraging because we can’t keep up with the demand. We have a waitlist of over 1,000 clients. It really highlights the mismatched supply and demand for therapists who take insurance.”

Prior to the COVID-19 pandemic, healthcare practitioners treating patients across state lines were forced to navigate a confusing patchwork of state laws governing licensing requirements. This complex legal landscape was a major barrier to telehealth.

Generally, states require physicians to be licensed to practice in the originating site’s state. However, some states also require the healthcare provider to be licensed in the state where the patient themself is physically located. To complicate things further, other states don’t specifically address telehealth/telemedicine licensing, but make allowances for practicing in contiguous states or in certain situations where a temporary license might be issued providing the specific state’s licensing conditions are met.

Before the pandemic, the state-by-state nature of licensing meant that most providers could not practice across state lines. “Prior to the COVID-19 pandemic, most states had rules where you were licensed by the state in which you practiced, and you could not practice across state lines. In some of the smaller states, they might have had reciprocity. In a state like Rhode Island, it’s so small, it’s easy for people to go to Massachusetts for care. But bigger states like California and Texas didn’t have [reciprocity]. When the pandemic hit, those regulations were relaxed so people could practice across state lines,” explains Dr. Traube.

Importantly, Dr. Traube notes that interstate licensing restrictions have particular impact in specialties with a dearth of providers. Take, for example, child psychiatrists. “We know we have too few child psychiatrists in this country. [Telehealth] makes it easier for physicians to earn a living and for patients to find adequate care. There’s pressure across the board for us to find a mechanism for physicians to practice telehealth while still protecting the safety of patients.”

Reallocating healthcare services to serve under-resourced communities benefits individuals, families, and communities. Returning to the example of behavioral health, although the Affordable Care Act (ACA) established allocations for behavioral health services, access to behavioral health services remains inadequate for many. And to date, increased access to telemental health services has not necessarily made therapy more inclusive. However, Dr. Traube remains hopeful: “Finding a provider is exceptionally difficult, so if we can lift some regulations and allocate resources from highly-served communities in major cities to less-served communities, that has the potential to even the playing field and hopefully reduce some of the disparities caused by lack of access.”

There are multiple efforts to allow physicians and healthcare providers to practice in multiple states without obtaining separate licenses in each jurisdiction. These compacts have been adopted to varying degrees across US states and territories. Generally, they have a ways to go before they’re adopted in enough states to achieve national-level coherence. Regardless, they represent meaningful progress and commitment to resolving licensing challenges in a comprehensive, national way.

Key compacts that would allow different medical professions to practice in multiple states are summarized below:

Dr. Singer explains that in her own field of psychology, PSYPACT increases access to patients regardless of geography beyond pandemic relaxations. “You sign up for an e-passport and can practice telehealth psychology in 30 different states and growing. It really opens up the practice to treat people in different states and communities. But there are also challenges with that: For one, how do you reach those clients and let them know about your services? You also need to make sure you can point them to the right local crisis resources should an emergency arise. Navigating some of those challenges and more of the logistics of billing and reimbursement can be difficult.”

In addition to adopting these compacts, states are also increasingly passing legislation directing healthcare professional boards to adopt practice standards for providers using telehealth. Organizations such as the California Emerging Technology Fund—which focuses on closing the digital divide—are also working on this issue.

During the pandemic, many modifications have been made to telehealth requirements. Much of telehealth’s recent expansion is directly attributable to the loosening of various rules at the federal and state levels.

At the federal level, four changes have helped to enable telehealth expansion:

1. Increased HIPAA flexibility via enforcement discretion and the waiving of penalties for HIPAA violations due to health care providers’ efforts to serve patients in good faith through everyday communications technologies (e.g., FaceTime or Skype) during the pandemic
2. The granting of telehealth waivers from the Centers for Medicare and Medicaid Services (CMS). These a) allow providers to conduct telehealth with patients in their homes and outside of designated rural areas, b) allow remote care across state lines via telehealth, c) allow delivery of care to new and established patients via telehealth, and d) allow telehealth services to be billed as if they were provided in person
3. Allowing Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to serve as distant telehealth sites and provide telehealth services to patients in their homes
4. The expansion of the list of covered telehealth services that can be provided in Medicare through telehealth to include emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services

States and territories have also made allowances to facilitate telemedicine during the pandemic. As of March 31, 2021, 41 states, Guam, the Northern Mariana Islands, and Puerto Rico had adopted various licensure waivers during COVID-19. Six states, the District of Columbia, and the US Virgin Islands either did not have, or had closed, their waivers. One state had waivers and was no longer allowing new applications.

Increased telehealth adoption has been facilitated by the expansion of telehealth coverage by both public and private payors.

As of May 2021, Medicaid programs in all states and the District of Columbia reimbursed for telehealth delivered via live video. Additionally, 22 Medicaid programs reimbursed for store-and-forward, 22 Medicaid programs reimbursed for remote patient monitoring, and 15 Medicaid programs allowed audio-only service delivery.

Many states had also expanded allowable care settings. 26 states and the District of Columbia allowed a patient’s home to be an eligible originating site under certain circumstances (making home-based service reimbursable). Additionally, 27 states and the District of Columbia reimbursed telehealth delivered in a school-based setting.

Although 42 states and the District of Columbia have laws governing private payor reimbursement of telehealth, the extent to which these laws require telehealth coverage to be on par with in-person services coverage varies widely. Some states require telehealth reimbursement to be equal to that of in-person coverage. However, most states require only parity in covered services. They do not set requirements with regard to reimbursement amounts. Furthermore, some state-level laws do not mandate reimbursement coverage parity, and few states have explicit payment parity.

Despite patchy state-level laws, many insurers temporarily expanded telehealth coverage during the pandemic. Some also made telehealth services free for a certain period of time, though as of June 2021, some of these policies have already expired.

Establishing care is another often-challenging issue in telehealth. Most states do not consider online questionnaires as meeting the standard for establishing a patient-provider relationship to prescribe medication. This means telehealth often cannot be the only means of care delivery for patients who require prescriptions. As a notable exception, the opioid epidemic has pushed some states to relax telehealth requirements for prescribing medication assisted therapy (MAT).

Other common restrictions related to telehealth are related to:

• Physical exams: some states allow telehealth to be used to conduct a physical exam, while others explicitly do not allow this or do not have policies on this topic
• Specialties: restrictions related to the types of specialties for which telehealth can be provided are common
• Types of services or CPT codes that can be reimbursed
• Types of providers that can be reimbursed

As the US emerges from the COVID-19 pandemic, there are signs that certain expansions of telehealth availability and affordability are likely to persist beyond the pandemic. This is evident in the CMS 2021 payment rule and other recommendations related to telehealth expansion over the next one to two years.

A number of changes to the Centers for Medicare & Medicaid Services’ (CMS) payment rule in 2021 expanded telehealth services on both temporary and permanent bases. The permanent additions included group psychotherapy services, some home visits for an established patient, and care planning services. The temporary coverage expansions, covering 144 telehealth services, included coverage for high-intensity home visits, emergency department visits, specialized therapy visits, nursing facility discharge day management, and more.

The originating site waiver, which allows people to consult with doctors from home in lieu of visiting a local facility, is likely to remain effective for some period of time. Per a suggestion by the Medicare Payment Advisory Commission (MedPAC), a nonpartisan legislative branch agency that provides Congress with analysis and policy advice on the Medicare program, coverage of audio-only visits and the telehealth service expansion are also likely to remain for at least one to two years after the end of the pandemic.

Similarly, many private payors have also expanded their telehealth reimbursement policies for 2021 through the end of the pandemic. These changes closely resemble the ones made by the CMS.

Given the significant length of time for which these telehealth expansions are now expected to be in place, it seems likely that patients will become accustomed to telehealth coverage by both private and public payors. This in itself is likely to make telehealth expansions from the pandemic era persist beyond the early 2020s. “I think it’s going to be hard for payors to roll back these policies,” suggests Dr. Singer. “Now that people are receiving all of these services, there will be a lot of resistance to stepping backward.”

There are a number of factors for healthcare and health technology organizations to consider as they integrate telehealth into their long-term plans. First, they must determine which services are well-suited to telehealth delivery and which are not. After the pandemic passes, the scope of services that healthcare organizations offer via telehealth may narrow as in-person appointments become more accessible and comfortable.

Second, healthcare organizations must invest in training personnel to effectively deliver telehealth. “One of the biggest misunderstandings about telehealth on the provider side is that it’s a one-to-one transfer from in-person to telehealth. We think that if we can see people in person, there’s no difference when seeing them on video. That’s just not the case. There are some transferable skills, but there are some adjustments that providers need to make. So it’s become really important to me that we are training providers in telehealth,” says Dr. Traube.

She continues, “If you look at educational programs, most med schools do not have modules for students to learn telehealth.” Assuming continued wide use of telehealth, it will be imperative that medical schools and healthcare institutions use classroom-based education and experiential training to train all students on how to deliver telehealth. For example, schools could use faculty-supervised standardized patient telehealth encounters to teach how telehealth should be delivered. They could also teach how to perform diagnostic or therapeutic procedures using telehealth equipment.

From an infrastructure perspective, it is important for providers to continue investing in technologies and services to enable telehealth. Here, Dr. Traube expresses some trepidation. “It can be challenging to have an infrastructure in your practice to provide both in-person and telehealth and to keep up with regulations around both of them. My fear is that providers, because of the hassle, will stop offering telehealth visits as frequently or as accessibly. One of the big mistakes that we’ve made in healthcare is making access so challenging for people, or dictating how people should get their care rather than listening to consumer desire and satisfaction. I think that leads to a lot of health disparities and distrust. My hope is that we’ll be able to develop a system that’s easy to navigate to offer as many options as possible.”

Given this, seamless infrastructure is an important enabler of continued telehealth availability. “Technology programs can really benefit the [telehealth] industry by creating programs that allow providers to schedule, see clients, chart medical records, and bill. There needs to be seamless infrastructure there.”

As healthcare providers and healthcare technology companies plan for the post-pandemic future, keeping changing technology needs and regulatory requirements in mind will be critical to success. Done right, telehealth promises to help create better access to high-quality care for all patients.